Discontinuation of HIV oral pre-exposure prophylaxis: findings from programmatic surveillance within two general population HIV programs in Nigeria.

BACKGROUND: As oral PrEP scales up in Nigeria, information about uptake, use pattern and client preference in a real-world, implementation setting is invaluable to guide refining service provision and incorporation of oral PrEP and other prevention measures into routine health services. To add to this body of knowledge, our study examines factors associated with discontinuation of PrEP among HIV negative individuals across two large scale programs in Nigeria. METHODS: Using program implementation data from two large-scale HIV projects in Akwa Ibom and Cross River states in Nigeria between January 2020 and July 2021, we used logistic regression to explore factors associated with early discontinuation (i.e., stopping PrEP within one month of starting) among HIV-negative individuals who initiated PrEP in the programs. RESULTS: Of a total of 26,325 clients; 22,034 (84%) discontinued PrEP within the first month. The odds of PrEP discontinuation were higher among clients who enrolled in community-based distribution sites (aOR 2.72; 95% C.I: 2.50-2.96) compared to those who enrolled in program-supported facilities and never married (aOR 1.76; 95% C.I: 1.61-1.92) compared to married clients. Clients who initiated PrEP because of high-risk sexual behaviour (aOR 1.15, 95% C.I 1.03-1.30) or inconsistent use or non-use of condoms (aOR 1.96, 95% C.I 1.60-2.41) had greater odds of discontinuing PrEPthan those who initiated PrEP because they were in a serodifferent relationship. CONCLUSION: The behavioural and demographic factors associated with early discontinuation of PrEP suggest that risk stratification of pre-initiation and follow up counselling may be helpful in raising continuation rates. On the service delivery side, strategies to strengthen follow-up services provided by community-based distribution sites need to be introduced. Overall, the low continuation rate calls for a review of programmatic approaches in provision of PrEP services in Nigeria.

Use of a hybrid digital training approach for hormonal IUD providers in Nigeria: results from a mixed method study.

BACKGROUND: In Nigeria, in-service trainings for new family planning (FP) methods have typically been conducted using a combination of classroom-based learning, skills labs, and supervised practicums. This mixed-methods study evaluated the feasibility, acceptability, provider competency, and costs associated with a hybrid digital and in-person training model for the hormonal intrauterine device (IUD). METHODS: The study was conducted in Enugu, Kano, and Oyo states, Nigeria, and enrolled FP providers previously trained on non-hormonal IUDs. Participants completed a digital didactic training, an in-person model-based practicum with an Objective Structured Clinical Examination (OSCE), followed by supervised provision of service to clients. Provider knowledge gains and clinical competency were assessed and described descriptively. Data on the feasibility, acceptability, and scalability of the approach were gathered from participating providers, clinical supervisors, and key stakeholders. Training costs were captured using an activity-based approach and used to calculate a cost per provider trained. All analyses were descriptive. RESULTS: Sixty-two providers took the hybrid digital training, of whom 60 (91%) were included in the study (n = 36 from public sector, n = 15 from private sector, and n = 9 both public/private). The average knowledge score increased from 62 to 86% pre- and post-training. Clinical competency was overall very high (mean: 94%), and all providers achieved certification. Providers liked that the digital training could be done at the time/place of their choosing (84%), was self-paced (79%), and reduced risk of COVID-19 exposure (75%). Clinical supervisors and Ministry of Health stakeholders also had positive impressions of the training and its scalability. The hybrid training package cost $316 per provider trained. CONCLUSIONS: We found that a hybrid digital training approach to hormonal IUD service provision in Nigeria was acceptable and feasible. Providers demonstrated increases in knowledge following the training and achieved high levels of clinical competency. Both providers and clinical supervisors felt that the digital training content was of high quality and an acceptable (sometimes preferable) alternative to classroom-based, in-person training. This study provided insights into a hybrid digital training model for a long-acting contraceptive, relevant to scale-up in Nigeria and similar settings.

Increased condom use among key populations using oral PrEP in Kenya: results from large scale programmatic surveillance.

BACKGROUND: Female sex workers (FSW) and men having sex with men (MSM) in Kenya have high rates of HIV infection. Following a 2015 WHO recommendation, Kenya initiated national scale-up of pre-exposure prophylaxis (PrEP) for all persons at high-risk. Concerns have been raised about PrEP users' potential changes in sexual behaviors such adopting condomless sex and multiple partners as a result of perceived reduction in HIV risk, a phenomenon known as risk compensation. Increased condomless sex may lead to unintended pregnancies and sexually transmitted infections and has been described in research contexts but not in the programmatic setting. This study looks at changes in condom use among FSW and MSM on PrEP through a national a scale-up program. METHODS: Routine program data collected between February 2017 and December 2019 were used to assess changes in condom use during the first three months of PrEP in 80 health facilities supported by a scale-up project, Jilinde. The primary outcome was self-reported condom use. Analyses were conducted separately for FSW and for MSM. Log-Binomial Regression with Generalized Estimating Equations was used to compare the incidence proportion ("risk") of consistent condom use at the month 1, and month 3 visits relative to the initiation visit. RESULTS: At initiation, 69% of FSW and 65% of MSM reported consistent condom use. At month 3, this rose to 87% for FSW and 91% for MSM. MSM were 24% more likely to report consistent condom use at month 1 (Relative Risk [RR], 1.24, 95% Confidence Interval [CI], 1.18-1.30) and 40% more likely at month 3 (RR, 1.40, 95% CI, 1.33-1.47) compared to at initiation. FSW were 15% more likely to report consistent condom use at the month one visit (RR, 1.15, 95% CI, 1.13-1.17) and 27% more likely to report condom use on the month 3 visit (RR 1.27, 95% CI, 1.24-1.29). CONCLUSION: Condom use increased substantially among both FSW and MSM. This may be because oral PrEP was provided as part of a combination prevention strategy that included counseling and condoms but could also be due to the low retention rates among those who initiated.

Keeping essential reproductive, maternal and child health services available during COVID-19 in Kenya, Mozambique, Uganda and Zimbabwe: analysis of early-pandemic policy guidelines.

BACKGROUND: The COVID-19 pandemic has disrupted the provision of essential reproductive, maternal, newborn, and child health (RMNCH) services in sub-Saharan Africa to varying degrees. Original models estimated as many as 1,157,000 additional child and 56,700 maternal deaths globally due to health service interruptions. To reduce potential impacts to populations related to RMNCH service delivery, national governments in Kenya, Mozambique, Uganda, and Zimbabwe swiftly issued policy guidelines related to essential RMNCH services during COVID-19. The World Health Organization (WHO) issued recommendations to guide countries in preserving essential health services by June of 2020. METHODS: We reviewed and extracted content related to family planning (FP), antenatal care (ANC), intrapartum and postpartum care and immunization in national policies from Kenya, Uganda, Mozambique, and Zimbabwe from March 2020 to February 2021, related to continuation of essential RMNCH services during the COVID-19 pandemic. Using a standardized tool, two to three analysts independently extracted content, and in-country experts reviewed outputs to verify observations. Findings were entered into NVivo software and categorized using pre-defined themes and codes. The content of each national policy guideline was compared to WHO guidance related to RMNCH essential services during COVID-19. RESULTS: All four country policy guidelines considered ANC, intrapartum care, FP, and immunization to be essential services and issued policy guidance for continuation of these services. Guidelines were issued in April 2020 by Mozambique, Kenya, and Uganda, and in June 2020 by Zimbabwe. Many elements of WHO's 2020 recommendations were included in country policies, with some notable exceptions. Each policy guideline was more detailed in some aspects than others - for example, Kenya's guidelines were particularly detailed regarding FP service provision, while Uganda's guidelines were explicit about immediate breastfeeding. All policy guidance documents contained a balance of measures to preserve essential RMNCH services while reducing COVID-19 transmission risk within these services. CONCLUSIONS: The national policy guidelines to preserve essential RMNCH services in these four countries reflected WHO recommendations, with some notable exceptions for ANC and birth companionship. Ongoing revision of country policy guidelines to adapt to changing pandemic conditions is recommended, as is further analysis of subnational-level policies.

Consistent Condom Use and Dual Protection Among Female Sex Workers: Surveillance Findings from a Large-Scale, Community-Based Combination HIV Prevention Program in Tanzania.

In Tanzania, HIV infection remains much higher among female sex workers (FSWs) than among other adult women. In addition to HIV, sexually transmitted infections (STIs) and pregnancy prevention are major concerns for FSWs in Tanzania. This study used a programmatic surveillance approach to examine protection against STIs/HIV and unintended pregnancy (dual method use) among FSWs in an outreach-based HIV prevention, care, and treatment program in Tanzania. 119,728 FSWs made a first visit to services served by the Sauti Project from January 2016 to September 2017. Of these 79,774 were current contraceptive users-of those, 4548 (5.7%) took a contraceptive as well as condoms, the study measure of dual family planning (FP) method use. Ninety-one percent (n = 4139) of FSWs taking dual FP methods were provided with an injectable in addition to condoms. Dual method use was lower in this study than in research studies in the region, highlighting potential differences between findings from research studies and evidence from a routine service provision setting. Self-reported consistent condom use among FSWs was 16.1%. The findings call for further research and programs to address FSW agency to increase dual protection against STIs/HIV and unintended pregnancy.

Outcomes and Experiences of Men and Women with Partner Notification for HIV Testing in Tanzania: Results from a Mixed Method Study.

A growing evidence base supports expansion of partner notification in HIV testing services (HTS) in sub-Saharan Africa. In 2015, a cross-sectional study was conducted in Njombe region, Tanzania, to evaluate partner notification within facility-based HTS. Men and women newly diagnosed with HIV were enrolled as index clients and asked to list current or past sexual partners for referral to HTS. Successful partner referral was 2.5 times more likely among married compared to unmarried index clients and 2.2 times more likely among male compared to female index clients. In qualitative analysis, male as well as female index clients mentioned difficulties notifying past or casual partners, and noted disease symptoms as a motivating factor for HIV testing. Female index clients mentioned gender-specific challenges to successful referral. Women may need additional support to overcome challenges in the partner notification process. In addition to reducing barriers to partner notification specific to women, a programmatic emphasis on social strengths of males in successfully referring partners should be considered.

Screening and management of pre-eclampsia and eclampsia in antenatal and labor and delivery services: findings from cross-sectional observation studies in six sub-Saharan African countries.

BACKGROUND: Preeclampsia and eclampsia (PE/E) are major contributors to maternal and neonatal deaths in developing countries, associated with 10-15% of direct maternal deaths and nearly a quarter of stillbirths and newborn deaths, many of which are preventable with improved care. We present results related to WHO-recommended interventions for screening and management of PE/E during antenatal care (ANC) and labor and delivery (L & D) from a study conducted in six sub-Saharan African countries. METHODS: From 2010 to 2012, cross-sectional studies which directly observed provision of ANC and L & D services in six sub-Saharan African countries were conducted. Results from 643 health facilities of different levels in Ethiopia (n = 19), Kenya (n = 509), Madagascar (n = 36), Mozambique (n = 46), Rwanda (n = 72), and Tanzania (n = 52), were combined for this analysis. While studies were sampled separately in each country, all used standardized observation checklists and inventory assessment tools. RESULTS: 2920 women receiving ANC and 2689 women in L & D were observed. Thirty-nine percent of ANC clients were asked about PE/E danger signs, and 68% had their blood pressure (BP) taken correctly (range 48-96%). Roughly half (46%) underwent testing for proteinuria. Twenty-three percent of women in L & D were asked about PE/E danger signs (range 11-34%); 77% had their BP checked upon admission (range 59-85%); and 6% had testing for proteinuria. Twenty-five cases of severe PE/E were observed: magnesium sulfate (MgSO4) was used in 15, not used in 5, and for 5 use was unknown. The availability of MgSO4 in L & D varied from 16% in Ethiopia to 100% in Mozambique. CONCLUSIONS: Observed ANC consultations and L & D cases showed low use of WHO-recommended practices for PE/E screening and management. Availability of MgSO4 was low in multiple countries, though it was on the essential drug list of all surveyed countries. Country programs are encouraged to address gaps in screening and management of PE/E in ANC and L & D to contribute to lower maternal and perinatal mortality.

Improvement in the active management of the third stage of labor for the prevention of postpartum hemorrhage in Tanzania: a cross-sectional study.

BACKGROUND: Tanzania has a maternal mortality ratio of 556 per 100,000 live births, representing 21% of all deaths of women of reproductive age. Hemorrhage, mostly postpartum hemorrhage (PPH), is estimated to cause at least 25% of maternal deaths in Tanzania. In 2008, the Ministry of Health, Community Development, Gender, Elderly and Children launched interventions to improve efforts to prevent PPH. Competency-based training for skilled birth attendants and ongoing quality improvement prioritized the practice of active management of the third stage of labor (AMTSL). METHODS: A cross-sectional study was conducted in 52 health facilities in Tanzania utilizing direct observations of women during labor and delivery. Observations were conducted in 2010 and, after competency-based training and quality improvement interventions in the facilities, in 2012. A total of 489 deliveries were observed in 2010 and 558 in 2012. Steps for AMTSL were assessed using a standardized structured observation checklist that was based on World Health Organization guidelines. RESULTS: The proportion of deliveries receiving all three AMTSL steps improved significantly by 19 percentage points (p < 0.001) following the intervention, with the most dramatic increase occurring in health centers and dispensaries (47.2 percentage point change) compared to hospitals (5.2 percentage point change). Use of oxytocin for PPH prevention rose by 37.1 percentage points in health centers and dispensaries but remained largely the same in hospitals, where the baseline was higher. There was substantial improvement in the timely provision of uterotonics (within 3 min of birth) across all facilities (p = 0.003). Availability of oxytocin, which was lower in health centers and dispensaries than hospitals at baseline, rose from 73 to 94% of all facilities. CONCLUSION: The quality of PPH prevention increased substantially in facilities that implemented competency-based training and quality improvement interventions, with the most dramatic improvement seen at lower-level facilities. As Tanzania continues with efforts to increase facility births, it is imperative that the quality of care also be improved by promoting use of up-to-date guidelines and ensuring regular training and mentoring for health care providers so that they adhere to the guidelines for care of women during labor. These measures can reduce maternal and newborn mortality.

Addressing the First 90: A Highly Effective Partner Notification Approach Reaches Previously Undiagnosed Sexual Partners in Tanzania.

To meet UNAIDS' 90-90-90 treatment goals, effective approaches to HIV testing services (HTSs) are urgently needed. In 2015, a cross-sectional study was conducted to evaluate effectiveness and feasibility of partner notification for HTS in Tanzania. Men and women newly diagnosed with HIV were enrolled as index clients, listed sexual partners, and given options to notify and link their partners to HTS. Of 653 newly diagnosed individuals, 390 index clients were enrolled, listed 438 sexual partners, of whom 249 (56.8%) were successfully referred. Of 249 partners reaching the facilities, 96% tested for HIV, 148 (61.9%) tested HIV+ (all newly diagnosed), and 104 (70.3%) of partners testing positive were enrolled into HIV care and treatment. Results showed good acceptability, feasibility and effectiveness, as evidenced by high uptake of partner notification among newly diagnosed individuals, over half of listed partners successfully referred, and a very high positivity rate among referred sexual partners.

What Messages are Adolescent Voluntary Medical Male Circumcision (VMMC) Clients Getting and How? Findings From an Observational Study in Tanzania.

Uncircumcised adolescent males in sub-Saharan Africa are an important group to reach with voluntary medical male circumcision (VMMC) services due to high HIV burden occurring among this age group. Appropriateness of the content and delivery of sexual health and HIV prevention messages to adolescent VMMC clients has not been extensively described. A study was conducted in Tanzania to examine quality, delivery and content of messages provided to adolescent (aged 15-19) and adult (aged 20+) VMMC clients (n = 320). Results show that counseling of mixed age groups during group education lacked selected key messages, compared to more age-homogeneous groups. Additionally, adolescents received more comprehensive information in individual counseling compared to group education. We recommend that health care providers are provided with skills and job aides to assist them to segment VMMC clients by age; provide age-appropriate messages; and increase use of individual counseling as a means to communicate with adolescent clients.

Equally able, but unequally accepted: Gender differentials and experiences of community health volunteers promoting maternal, newborn, and child health in Morogoro Region, Tanzania.

BACKGROUND: Despite emerging qualitative evidence of gendered community health worker (CHW) experience, few quantitative studies examine CHW gender differentials. The launch of a maternal, newborn, and child health (MNCH) CHW cadre in Morogoro Region, Tanzania enlisting both males and females as CHWs, provides an opportunity to examine potential gender differences in CHW knowledge, health promotion activities and client acceptability. METHODS: All CHWs who received training from the Integrated MNCH Program between December 2012 and July 2013 in five districts were surveyed and information on health promotion activities undertaken drawn from their registers. CHW socio-demographic characteristics, knowledge, and health promotion activities were analyzed through bi- and multivariate analyses. Composite scores generated across ten knowledge domains were used in ordered logistic regression models to estimate relationships between knowledge scores and predictor variables. Thematic analysis was also undertaken on 60 purposively sampled semi-structured interviews with CHWs, their supervisors, community leaders, and health committee members in 12 villages from three districts. RESULTS: Of all CHWs trained, 97% were interviewed (n = 228): 55% male and 45% female. No significant differences were observed in knowledge by gender after controlling for age, education, date of training, marital status, and assets. Differences in number of home visits and community health education meetings were also not significant by gender. With regards to acceptability, women were more likely to disclose pregnancies earlier to female CHWs, than male CHWs. Men were more comfortable discussing sexual and reproductive concerns with male, than female CHWs. In some cases, CHW home visits were viewed as potentially being for ulterior or adulterous motives, so trust by families had to be built. Respondents reported that working as female-male pairs helped to address some of these dynamics. CONCLUSIONS: Male and female CHWs in this study have largely similar knowledge and health promotion outputs, but challenges in acceptance of CHW counseling for reproductive health and home visits by unaccompanied CHWs varied by gender. Programs that pair male and female CHWs may potentially overcome gender issues in CHW acceptance, especially if they change gender norms rather than solely accommodate gender preferences.

Uterotonic use immediately following birth: using a novel methodology to estimate population coverage in four countries.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in developing countries. While incidence of PPH can be dramatically reduced by uterotonic use immediately following birth (UUIFB) in both community and facility settings, national coverage estimates are rare. Most national health systems have no indicator to track this, and community-based measurements are even more scarce. To fill this information gap, a methodology for estimating national coverage for UUIFB was developed and piloted in four settings. METHODS: The rapid estimation methodology consisted of convening a group of national technical experts and using the Delphi method to come to consensus on key data elements that were applied to a simple algorithm, generating a non-precise national estimate of coverage of UUIFB. Data elements needed for the calculation were the distribution of births by location and estimates of UUIFB in each of those settings, adjusted to take account of stockout rates and potency of uterotonics. This exercise was conducted in 2013 in Mozambique, Tanzania, the state of Jharkhand in India, and Yemen. RESULTS: Available data showed that deliveries in public health facilities account for approximately half of births in Mozambique and Tanzania, 16% in Jharkhand and 24% of births in Yemen. Significant proportions of births occur in private facilities in Jharkhand and faith-based facilities in Tanzania. Estimated uterotonic use for facility births ranged from 70 to 100%. Uterotonics are not used routinely for PPH prevention at home births in any of the settings. National UUIFB coverage estimates of all births were 43% in Mozambique, 40% in Tanzania, 44% in Jharkhand, and 14% in Yemen. CONCLUSION: This methodology for estimating coverage of UUIFB was found to be feasible and acceptable. While the exercise produces imprecise estimates whose validity cannot be assessed objectively in the absence of a gold standard estimate, stakeholders felt they were accurate enough to be actionable. The exercise highlighted information and practice gaps and promoted discussion on ways to improve UUIFB measurement and coverage, particularly of home births. Further follow up is needed to verify actions taken. The methodology produces useful data to help accelerate efforts to reduce maternal mortality.

Improvements in newborn care and newborn resuscitation following a quality improvement program at scale: results from a before and after study in Tanzania.

BACKGROUND: Every year, more than a million of the world's newborns die on their first day of life; as many as two-thirds of these deaths could be saved with essential care at birth and the early newborn period. Simple interventions to improve the quality of essential newborn care in health facilities - for example, improving steps to help newborns breathe at birth - have demonstrated up to 47% reduction in newborn mortality in health facilities in Tanzania. We conducted an evaluation of the effects of a large-scale maternal-newborn quality improvement intervention in Tanzania that assessed the quality of provision of essential newborn care and newborn resuscitation. METHODS: Cross-sectional health facility surveys were conducted pre-intervention (2010) and post intervention (2012) in 52 health facilities in the program implementation area. Essential newborn care provided by health care providers immediately following birth was observed for 489 newborns in 2010 and 560 in 2012; actual management of newborns with trouble breathing were observed in 2010 (n = 18) and 2012 (n = 40). Assessments of health worker knowledge were conducted with case studies (2010, n = 206; 2012, n = 217) and a simulated resuscitation using a newborn mannequin (2010, n = 299; 2012, n = 213). Facility audits assessed facility readiness for essential newborn care. RESULTS: Index scores for quality of observed essential newborn care showed significant overall improvement following the quality-of-care intervention, from 39% to 73% (p <0.0001). Health worker knowledge using a case study significantly improved as well, from 23% to 41% (p <0.0001) but skills in resuscitation using a newborn mannequin were persistently low. Availability of essential newborn care supplies, which was high at baseline in the regional hospitals, improved at the lower-level health facilities. CONCLUSIONS: Within two years, the quality improvement program was successful in raising the quality of essential newborn care services in the program facilities. Some gaps in newborn care were persistent, notably practical skills in newborn resuscitation. Continued investment in life-saving improvements to newborn care through the health services is a priority for reduction of newborn mortality in Tanzania.

Integrating HIV testing into cervical cancer screening in Tanzania: an analysis of routine service delivery statistics.

BACKGROUND: While the lifetime risk of developing cervical cancer (CaCx) and acquiring HIV is high for women in Tanzania, most women have not tested for HIV in the past year and most have never been screened for CaCx. Good management of both diseases, which have a synergistic relationship, requires integrated screening, prevention, and treatment services. The aim of this analysis is to assess the acceptability, feasibility and effectiveness of integrating HIV testing into CaCx prevention services in Tanzania, so as to inform scale-up strategies. METHODS: We analysed 2010-2013 service delivery data from 21 government health facilities in four regions of the country, to examine integration of HIV testing within newly introduced CaCx screening and treatment services, located in the reproductive and child health (RCH) section of the facility. Analysis included the proportion of clients offered and accepting the HIV test, reasons why testing was not offered or was declined, and HIV status of CaCx screening clients. RESULTS: A total of 24,966 women were screened for CaCx; of these, approximately one-quarter (26%) were referred in from HIV care and treatment clinics. Among the women of unknown HIV status (n = 18,539), 60% were offered an HIV test. The proportion of women offered an HIV test varied over time, but showed a trend of decline as the program expanded. Unavailability of HIV test kits at the facility was the most common reason for a CaCx screening client not to be offered an HIV test (71% of 6,321 cases). Almost all women offered (94%) accepted testing, and 5% of those tested (582 women) learned for the first time that they were HIV-positive. CONCLUSION: Integrating HIV testing into CaCx screening services was highly acceptable to clients and was an effective means of reaching HIV-positive women who did not know their status; effectiveness was limited, however, by shortages of HIV test kits at facilities. Integration of HIV testing into CaCx screening services should be prioritized in HIV-endemic settings, but more work is needed to eliminate logistical barriers. The coverage of CaCx screening among HIV care and treatment-enrolled women in Tanzania may be low and should be examined.

Penile measurements in Tanzanian males: guiding circumcision device design and supply forecasting.

PURPOSE: Voluntary medical male circumcision decreases the risk in males of HIV infection through heterosexual intercourse by about 60% in clinical trials and 73% at post-trial followup. In 2007 WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that countries with a low circumcision rate and high HIV prevalence expand voluntary medical male circumcision programs as part of a national HIV prevention strategy. Devices for adult/adolescent male circumcision could accelerate the pace of scaling up voluntary medical male circumcision. Detailed penile measurements of African males are required for device development and supply size forecasting. MATERIALS AND METHODS: Consenting males undergoing voluntary medical male circumcision at 3 health facilities in the Iringa region, Tanzania, underwent measurement of the penile glans, shaft and foreskin. Age, Tanner stage, height and weight were recorded. Measurements were analyzed by age categories. Correlations of penile parameters with height, weight and body mass index were calculated. RESULTS: In 253 Tanzanian males 10 to 47 years old mean ± SD penile length in adults was 11.5 ± 1.6 cm, mean shaft circumference was 8.7 ± 0.9 cm and mean glans circumference was 8.8 ± 0.9 cm. As expected, given the variability of puberty, measurements in younger males varied significantly. Glans circumference highly correlated with height (r = 0.80) and weight (r = 0.81, each p <0.001). Stretched foreskin diameter moderately correlated with height (r = 0.68) and weight (r = 0.71, each p <0.001). CONCLUSIONS: Our descriptive study provides penile measurements of males who sought voluntary medical male circumcision services in Iringa, Tanzania. To our knowledge this is the first study in a sub-Saharan African population that provides sufficiently detailed glans and foreskin dimensions to inform voluntary medical male circumcision device development and size forecasting.

Use of Objective Structured Clinical Examination (OSCE) in a hybrid digital / in-person training for hormonal IUD in Nigeria: findings and applications of the approach.

Background: The hormonal intrauterine device, a long-acting reversible contraceptive method, is being introduced to pilot sites in the private and public sector in Nigeria by the Nigerian Federal Ministry of Health since 2019. To inform training of health care providers, a study was conducted on a hybrid digital and in-person training which utilized Objective Structured Clinical Examination (OSCE) to assess competency of provider trainees. This study represents one of few documented experiences using OSCE to assess the effectiveness of a digital training. Methods: From September - October 2021, in Enugu, Kano and Oyo states of Nigeria, 62 health care providers from public and private sector health facilities were trained in hormonal IUD service provision using a hybrid digital / in-person training approach. Providers, who were skilled in provision of copper IUD, underwent a didactic component using digital modules, followed by an in-person practicum, and finally supervised service provision in the provider trainee's workplace. Skills were assessed using OSCE during the one-day practicum. Results: Use of the OSCE to assess skills provided valuable information to study team. The performance of provider trainees was high (average 94% correct completion of steps in the OSCE). Conclusions: OSCE was used as a research methodology as part of this pilot study; to date, OSCE has not been integrated into the training approach to be scaled up by FMOH. Uniformly high performance of provider trainees was seen on the OSCE, unsurprising since provider trainees were experienced in providing copper IUD. If and when training is rolled out to providers inexperienced with copper IUD, OSCE may have a more important role to assess skills before service provision. The role of OSCE in design of hybrid digital / in-person training approaches should be further explored in rollout of hormonal IUD and other contraceptive technologies.

Voluntary medical male circumcision: matching demand and supply with quality and efficiency in a high-volume campaign in Iringa Region, Tanzania.

The government of Tanzania has adopted voluntary medical male circumcision (VMMC) as an important component of its national HIV prevention strategy and is scaling up VMMC in eight regions nationwide, with the goal of reaching 2.8 million uncircumcised men by 2015. In a 2010 campaign lasting six weeks, five health facilities in Tanzania's Iringa Region performed 10,352 VMMCs, which exceeded the campaign's target by 72%, with an adverse event (AE) rate of 1%. HIV testing was almost universal during the campaign. Through the adoption of approaches designed to improve clinical efficiency-including the use of the forceps-guided surgical method, the use of multiple beds in an assembly line by surgical teams, and task shifting and task sharing-the campaign matched the supply of VMMC services with demand. Community mobilization and bringing client preparation tasks (such as counseling, testing, and client scheduling) out of the facility and into the community helped to generate demand. This case study suggests that a campaign approach can be used to provide high-volume quality VMMC services without compromising client safety, and provides a model for matching supply and demand for VMMC services in other settings.

Unmet Need for Contraception Among Female Sex Workers Initiating Oral Pre-Exposure Prophylaxis for HIV Prevention During Kenya's National Scale-Up: Results From a Programmatic Surveillance Study.

Background: Female sex workers (FSWs) experience a higher risk for both HIV acquisition and unwanted pregnancies compared to women in the general population. Pre-exposure prophylaxis (PrEP) for HIV prevention offers protection against HIV infection but has no contraceptive effect. We examined the determinants of unmet need for contraception among FSWs who initiated PrEP to inform programs and policies to optimize contraceptive services and avert unwanted pregnancy among this high-risk group. Materials and Methods: A cross-sectional analysis was conducted on routine, de-identified client data from a large-scale PrEP service delivery project, from February 2017 to December 2019. Data were collected from FSWs during clinic visits using Ministry of Health approved tools. Records for all 17,456 FSWs initiated on PrEP from 79 health facilities in 10 counties across three geographic clusters with high and medium HIV incidence were examined for eligibility for the analysis. Unmet need for non-barrier contraception was defined as not being pregnant, not currently using the non-barrier contraceptive method, and not trying to conceive or intending to have a child in the near future. Univariate and multivariable regression analyses were conducted with selected variables to examine associations. Results: In the 79 sites, eligible records from 17,063 FSWs who initiated PrEP were included. Two-thirds were under 30 years, and the majority were not married and had received PrEP at drop-in centers. Overall, the unmet need for non-barrier contraception was 52.6%, higher for those under 20 years of age (60.9%) and those served in public and private health facilities (67.4 and 83.2%, respectively) rather than drop-in centers (50.6%). Women from the Nairobi and Coast cluster regions reported a higher unmet need for contraception compared to those from the Lake region. All these associations were significant (p < 0.05) at the multivariate level. Conclusions: The high unmet need for non-barrier contraception among FSWs initiating PrEP highlights the need for integrated delivery of contraception services within PrEP programs. Identifying groups with a high unmet need could lead to higher success in an integrated program. Two recommended approaches include training healthcare providers to deliver clear contraception messaging during PrEP initiation and making a range of contraceptives accessible within PrEP services for high-risk groups. Furthermore, accelerated research on multipurpose prevention technologies is necessary to reduce the burden on individuals using multiple prevention products concurrently.

An implementation model for scaling up oral pre-exposure prophylaxis in Kenya: Jilinde project.

Oral pre-exposure prophylaxis (PrEP) is an efficacious way to lower the risk of HIV acquisition among high-risk individuals. Despite the World Health Organization's 2015 recommendation that all persons at substantial risk of HIV infection be provided with access to oral PrEP, the rollout has been slow in many low- and middle-income countries. Initiatives for national rollout are few, and subtle skepticism persists in several countries about the feasibility of national PrEP implementation. We describe the conceptual design of the Jilinde project, which is implementing oral PrEP as a routine service at a public health scale in Kenya. We describe the overlapping domains of supply, demand, and government and community ownership, which combine to produce a learning laboratory environment to explore the scale-up of PrEP. We describe how Jilinde approaches PrEP uptake and continuation by applying supply and demand principles and ensures that government and community ownership informs policy, coordination, and sustainability. We describe the "learning laboratory" approach that informs strategic and continuous learning, which allows for adjustments to the project. Jilinde's conceptual model illustrates how the coalescence of these concepts can promote scale-up of PrEP in real-world conditions and offers critical lessons on an implementation model for scaling up oral PrEP in low- and middle-income countries.

Systematic review of Doppler for detecting intrapartum fetal heart abnormalities and measuring perinatal mortality in low- and middle-income countries.

BACKGROUND: Using Doppler to improve detection of intrapartum fetal heart rate (FHR) abnormalities coupled with appropriate, timely intrapartum care in low- and middle-income countries (LMIC) can save lives. OBJECTIVE: To review studies using Doppler to improve detection of intrapartum FHR abnormalities and intrapartum care quality in LMIC health facilities. SEARCH STRATEGY: PubMed, Web of Science, Embase, Global Health, and Scopus were searched from inception to October 2018 by combining terms for Doppler, perinatal outcomes, and FHR monitoring. SELECTION CRITERIA: Selected studies compared Doppler and Pinard stethoscope for detecting/monitoring intrapartum FHR, or described provider and maternal preferences for FHR monitoring in LMIC settings. DATA COLLECTION AND ANALYSIS: Two team members independently screened and collected data. Risk of bias was assessed by Cochrane EPOC criteria. RESULTS: Eleven studies from eight countries were included. Doppler was superior at detecting abnormal intrapartum FHR as compared with Pinard stethoscope, but was not associated with improved perinatal outcomes. Using Doppler on admission helped to accurately measure perinatal deaths occurring after facility admission. CONCLUSION: Studies and program learning are needed to translate improved detection of FHR abnormalities to improved case management in LMICs. Doppler should be used to calculate a facility indicator of intrapartum care quality. PROSPERO registration: CRD42019121924.